Top Performer on Joint Commission Key Quality Measures® Program
How to Determine “Top Performer” Status – Program Criteria
Being Applied to 2014 Data for 2015 Recognition
Who is Eligible for the Program?
Joint Commission-accredited hospitals and critical access hospitals reporting ORYX data on one or more core measure
sets, which contain accountability measures identified for inclusion in The Joint Commission’s calculation of
accountability measure composite rates for calendar year 2014, are eligible for consideration.
What are the Prerequisites to being Eligible for the Program?
o Hospitals and critical access hospitals must have submitted at least 12 calendar months of data on at least one
core measure set. Note: Seasonal measures e.g., influenza immunization, will be included if two calendar quarters of data
exist for the calendar year under consideration.
o The sum of all the denominator cases for all accountability measures submitted must be ≥ 30.
o Hospitals not meeting these minimum requirements are excluded from consideration for the Top
Performer program.
How is the Overall Recognition and Core Measure Set Designation(s) Determined?
Recognition as a Top Performer is determined using a three-step process. To be recognized as a Top Performer, a
hospital must successfully meet all of the criteria in the three steps outlined below. For additional detailed information,
please see Attachments A and B.



Step 1 - Overall Composite Rate ≥ 95%
o A hospital must achieve a composite rate across all reported accountability measures that is ≥ 95% (based on
the rate obtained from the combined 12 calendar months of data). Data on all designated accountability
measures across all core measure sets for which the hospital submits data for the calendar year under
consideration will be included in the calculation.
Step 2 - Each and Every Accountability Measure ≥ 95%
o A hospital must achieve a rate ≥ 95% on each and every applicable reported accountability measure where
there are at least 30 denominator cases (based on the rate obtained from the combined 12 calendar months of
data).
Step 3 – Core Measure Set Designation
o A hospital must first be identified as a Top Performer (meet Step 1 and 2) and have at least one core measure
set that has:
 A core measure set composite rate ≥ 95% (based on the rate obtained from the combined 12
calendar months of data)
 All applicable individual accountability measures with a rate that is ≥ 95% (based on the rate
obtained from the combined 12 calendar months of data)
Which Accountability Measures will be Considered for 2014 (2015 Recognition)?
The complete list of accountability measures that will be used in the review of 2014 data (2015 recognition) will be
posted on the Top Performer program section of The Joint Commission’s website at:
www.jointcommission.org/accreditation/top_performers.aspx during the fall.
What are the Specific Calculations Used in each of the Three Steps?
 Attachment A (Detailed Calculation Information/Measure Clarifications) - provides detailed calculation
information along with measure-specific clarifications for 2014 data.
 Attachment B (Health Care Organization Eligibility Criteria Diagram) - provides detailed calculation
information as a flow diagram.
Questions?
Please contact the Top Performer Program at topperformersprogram@jointcommission.org.
Attachment A
The Joint Commission’s Top Performer on Key Quality Measures® Program How to Determine “Top Performer” Status – Detailed Calculation Information
Being Applied to 2014 Data for 2015 Recognition
Step 1 - Overall Composite Rate ≥95%
To determine whether the hospital meets the criteria for Step 1, the following analysis is completed:
Divide the sum of all the reported accountability measure numerators for the calendar year by the sum of all the
reported accountability measure denominators. This calculation must be ≥ 95% to meet Step 1.
Notes:
a. The sum of all the reported accountability measure denominators must be ≥ 30 for this criterion to be
met.
b. Accountability measures reported for less than 12 months during 2014 (less than 6 months for
seasonal measures, e.g., influenza immunization) are excluded from this calculation.
c. Accountability measures with denominators of less than 30 cases are included in this calculation.
Step 2 - Each and Every Accountability Measure ≥ 95%
To determine whether the hospital meets the criteria for Step 2, the following analysis is completed:
For each individually reported accountability measure, divide the numerator by the denominator. Each of these
calculations must be ≥ 95% to meet Step 2.
Notes:
a. Accountability measures with denominators of less than 30 cases are not considered when
determining whether this criterion is met.
b. Accountability measures reported for less than 12 months during 2014 (less than 6 months for
seasonal measures, e.g., influenza immunization) are not considered when determining whether this
criterion is met.
c. If all the reported accountability measures have denominators less than 30, then the organization
is not eligible to be listed.
Step 3 – Core Measure Set Designation
To determine which core measure set(s) will be designated for hospitals identified as a Top Performer, both
of the following criteria must be met for each core measure set:

The calculated composite rate for all accountability measures reported within a particular core measure set
must be ≥ 95%.
To determine:
Using only the accountability measures within a particular measure set, divide the sum of all the
reported numerators by the sum of all the reported denominators. This calculation must be ≥ 95% to
qualify the core measure set.
Notes:
a. If the sum of the denominators for the accountability measures in the set is less than 30, then
the organization is not eligible to have this core measure set listed.
b. Accountability measures reported for less than 12 months during 2014 (less than 6 months
for seasonal measures, e.g., influenza immunization) are not considered when determining
whether this criterion is met.
c.

Accountability measures with denominators of less than 30 cases are included in this
calculation.
Reported rates for each individual accountability measure within the core measure set must
be ≥ 95%.
To determine:
For each individually reported accountability measure within a particular core measure set, divide the
numerator by the denominator. Each of these calculations must be ≥ 95% to have the core measure
set recognized for the Top Performer program.
Notes:
a. Accountability measures with denominators of less than 30 cases are not considered when
determining whether this criterion is met.
b. Accountability measures reported for less than 12 months during 2014 (less than 6 months
for seasonal measures, e.g., influenza immunization) are not considered when determining
whether this criterion is met.
c.
If all the reported accountability measures within a particular core measure set(s) have
denominators less than 30, then the organization is not eligible to have this core measure
set listed.
Important Clarifications:


Actual measure rates are used to determine Top Performer eligibility; the rates are not rounded up.
All ORYX data are considered final as of the 4Q transmission deadline in April; no retransmission data
received after April 30 are applied to the program.
Prerequisites, Step 1, and Step 2
Joint Commission’s Top Performers on Key Quality Measures™ Program
Health Care Organization Eligibility Criteria Diagram
START
All HCOs reporting ORYX Core measure sets
with Accountability Measures
HCO submitted at least
1 or more ORYX Core
measure sets
Yes
Prerequisites
No
HCO submitted
12 mo. of data for at least 1 Core
measure set (≥ 2 CY qtrs
for seasonal measures)
No
Yes
Sum of all reported
accountability measure denominators
(across all sets) is ≥ 30
Begin Step 1
Step 1 – Overall
Composite Rate ≥ 95%
Begin Step 2
Step 2 – Each and
Every Accountability
Measure ≥ 95%
No
Yes
The overall composite
rate for all submitted accountability
measures is ≥ 95 %
Yes
The Joint Commission excludes individual accountability measures with
less than 30 denominator cases.
Cont.
Step 2
No
HCO
excluded
Step 2 Continued
Cont.
Step 2
Step 2 – Each and
Every Accountability
Measure ≥ 95%
HCO has
at least one accountability
measure that has a denominator
count ≥ 30
HCO
excluded
Yes
Every individual
accountability measure with a
denominator count ≥ 30
has a rate ≥ 95%
Yes
CONTINUE to Step 3 for determination of measure set(s).
Begin Step 3
Step 3 – Measure Set
Designation(s)
No
Step 3
No
HCO is excluded
from Top Performers
recognition
Step
3
Step 3
Set Top Performer Measure Set Counter = 0
Each core measure set submitted by each HCO goes through the
following flow to determine set recognition
Any individual accountability measure with less than 12 months of data is excluded
At least
1 accountability measure in
a set has 12 mo. of data (≥ 2 CY
qtrs for seasonal
measures)
Step 3 –
Measure Set
Designation
No
Yes
Sum of all
accountability measures
denominators in
the set ≥ 30
No
Yes
Composite rate for
all accountability measures
in the set ≥ 95%
No
Yes
Yes
The Joint Commission excludes each individual accountability measure
within the given set with less than 30 denominator cases.
HCO
has at least 1
accountability measure within the
Core measure set with a
denominator count
≥ 30
No
Yes
HCO is recognized
as a Top Performer
for this Core
Measure Set
Every individual
accountability measure with a
denominator count ≥ 30 in the
set has a rate
≥ 95%
Yes
No
Add 1 to Top Performer
Measure Set Counter
HCO
submitted another measure
set
No
HCO is recognized
as a Top Performer
Yes
Top
Performer Measure Set
Counter ≥ 1
STOP
No
HCO is excluded
from Top Performers
recognition
Core Measure Set
is excluded from
Top Performers
recognition